Throughout life, human beings confront threats to their lives and well-being, such as acts of nature, pollutants, communicable diseases, accidents, and crime. Normally, adults take preventive action to avoid these hazards and, should they occur, attempt to control them to minimize their impact. Older persons face the same hazards as any adult, but their risks are compounded by age-related factors that reduce their capacity to protect themselves from and increase their vulnerability to safety hazards. Gerontological nurses need to identify safety risks when assessing older adults and provide interventions to address existing and potential threats to safety, life, and well-being. Age-related changes can reduce the capacity of older adults to protect themselves from injury and increase their vulnerability to safety hazards.
Accidents are among the top 10 causes of death in those over 65. Accidents rank as the ninth leading cause of injury-related deaths. *Older women have a higher rate of injuries than any adult female age group. The death rate from accidents is significant among the older population as compared to other adult age groups. *Older adults 85+ years have the highest death rate of all from injuries and accidents (Table 17-2, p. 192). *Falls are far and away the most common cause of injury and subsequent death from injury in seniors.
Age-related changes, altered antigen-antibody response, and the high prevalence of chronic disease cause older persons to be highly susceptible to infections. Pneumonia and influenza rank as the SEVENTH leading cause of death in this age, and pneumonia is the leading cause of infection-related death (note change from Table 1-4 in text). Older adults have a threefold greater incidence of nosocomial pneumonia as compared with younger age groups, older adults experience gastroenteritis caused by Salmonella species more frequently than persons younger than 65 years of age; and urinary tract infections increase in prevalence with age. Older adults account for more than half of all reported cases of tetanus, endocarditis, cholelithiasis, and diverticulitis. Atypical symptomatology often results in delayed diagnosis of infection, contributing to older adults’ higher mortality rate from infections; for instance, older persons are more likely to die from appendicitis than younger persons due to the altered presentation of symptoms delaying diagnosis. Not only do infections develop more easily in the elderly, but they also are more difficult to identify early because of altered symptomatology. That is, the atypical presentation of symptoms can complicate early identification and correction. Infection should be suspected whenever any abrupt, unexplained change in physical or mental function is detected in the elderly patient. Atypical presentation of illness in older adults includes absence of fever and cough, anorexia, confusion, dizziness, falls, fatigue, new-onset incontinence, lethargy, level of consciousness changes, malaise, self-neglect, and unexplained weight loss.
*Case Study* Altered pharmacokinetics, self-administration problems, and the high volume of drugs consumed by older individuals can also lead to considerable risks to safety. Risks include adverse effects and accidents resulting from effects such as drowsiness or dizziness. It is estimated that 5% to 30% of geriatric admissions to hospitals are associated with inappropriate drug administration. Pharmacokinetics – what the body does to the drug. Absorption, Distribution, Metabolism and Excretion. With aging, the metabolism and excretion of many drugs decrease, and the physiologic changes of aging require dose adjustment for some drugs. Pharmacodynamics – what the drug does to the body – changes in drug receptors
“B” Total body water tends to decrease with age, while total body fat tends to increase with age.
True. Adverse reactions and side effects of medications can result in accidents from drowsiness or dizziness. It is estimated that 5% to 30% of geriatric admissions to hospitals are associated with inappropriate drug administration.
The environment can be considered in two parts, the microenvironment and the macroenvironment. The microenvironment refers to our immediate surroundings with which we closely interact (e.g., furnishings, wall coverings, lighting, room temperature, and room sounds). The macroenvironment consists of the elements in the larger world that affect groups of people or even entire populations (e.g., the weather, pollution, traffic, and natural resources). Although nurses should be concerned with improving the macroenvironment to benefit public health, the microenvironment, which can be more easily manipulated and from which more immediate benefits can be realized, is the focus of this discussion. The environment is a statement by and to us, an expression of our unique selves. Whether it is filled with family heirlooms, accented by our handiwork, dramatic in design, or stark and simple, our environment expresses a great deal about our preferences, attitudes, lifestyles, and personalities. Ideally, the environment provides more than shelter; it should promote continued development, stimulation, and satisfaction to enhance our psychological well-being. This is particularly important for older adults, many of whom spend considerable time in their homes or in a bedroom of an institution and have reduced interaction with the larger environment of their communities. To achieve the fullest satisfaction from their microenvironments, older adults must have various levels of needs met within their surroundings. This can be exemplified by comparing environmental needs with the basic human needs postulated by Maslow.
Limitations imposed by highly prevalent chronic diseases create special environmental problems for older people, such as those listed in Table 17-5 (p. 195): Stiff joints, balance problems, vision problems Specific disabilities accompany various diseases and create unique environmental problems, as is witnessed with a person who is cognitively impaired. Based on common limitations found among older people, most older people need an environment that is safe, functional, comfortable, personal, and normalizing and that compensates for their limitations. Creating such an environment requires considering lighting, temperature, colors, scents, floor coverings, furniture, sensory stimulation, noise control, bathroom hazards, and psychosocial factors. Box 17-1 (p. 196) provides a checklist for assessing basic standards for the older adults environment.
Light has a more profound affect than simply illuminating an area for better visibility. For example, light affects the following: Function – An individual may be more mobile and participate in more activities in a brightly lit area, whereas a person in a dim room may be more sedate. Orientation – An individual may lose the perspective of time in a room that is constantly lit or darkened for long periods. For example, persons exposed to the bright lighting in intensive care units for several days often cannot determine if it is day or night. A person who awakens in a pitch-dark room may be disoriented for a few seconds. Mood and behavior – Blinking psychedelic lights cause a different reaction from candlelight. In restaurants, customers are quieter and eat more slowly with soft, low illumination levels than with harsh, high ones.
Several diffuse lighting sources rather than a few bright ones are best in areas used by older adults. Fluorescent lights are the most bothersome because of eye strain and glare. The use of fluorescent lighting for economic reasons actually may not be cost effective; although less expensive to operate, they have higher maintenance costs. Sunlight should be filtered by sheer curtains. The nurse should assess the environment for glare, paying particular attention to light bouncing off shining floors and furniture. Evaluate lighting from a seated position because insufficient lighting, shadows, glare, and other problems can appear differently from chair or bed level than from a standing position. Nightlights help facilitate orientation during the night and provide visibility to locate light switches or lamps for nighttime mobility. A soft red light can be useful at night in the bedroom to improve night vision. Always keep a charged flashlight near your bed for emergencies. Exposure to natural light during the normal 24-hour dark-light cycle helps to maintain body rhythms, which, in turn, influence body temperature, sleep cycles, hormone production, and other functions. When the sleep-wake cycle is interrupted, the body’s internal rhythms can be disrupted. This factor warrants consideration in hospital and nursing home settings, where areas may be lit around the clock to facilitate staff activities; darkening areas at night can assist in maintaining normal body rhythms. Nurses should also consider the lack of exposure to natural sunlight often experienced by institutionalized or homebound ill older individuals. Consideration should be given to taking these individuals outdoors, when possible, and opening windows to allow sunlight to ensue.
Hot and cold temperatures profoundly affect human beings. Body temperature affects performance.Sensitivity to touch, ability to stay focused and vigilant with a task performance, and ability to perform psychomotor tasks become impaired in temperatures below 55 degrees F (13 degrees C). Older adults are sensitive to lower environmental temperatures because of their lower body temperature and decreased amount of natural insulation. Thin skin and less subcutaneous fat insulation. The normal body temperature of older adults is often lower than that of younger people. Thus, maintaining adequate environmental temperatures is significant to help prevent hypothermia. Important to maintain warm environment to prevent hypothermia. The recommended room temperature should not be lower than 75 degrees F (24 degrees C). The older the person is, the narrower the range of temperatures tolerated without adverse reactions. Room temperatures less than 70 degrees F (21 degrees C) can lead to hypothermia in older adults. Although not as significant a problem as hypothermia, hyperthermia can also create difficulty for older persons, who are more susceptible to its ill effects than younger adults. Brain damage can result from temperatures exceeding 106 degrees F (41 degrees C). Even in geographic areas that do not experience excessively high temperatures, consideration must be given to the temperature of rooms or homes in which doors and windows are not opened and no air conditioning is present. Persons with diabetes or cerebral atherosclerosis are at high risk for becoming hyperthermic.
True. The older the person is, the narrower the range of temperatures tolerated without adverse reactions. Recommended room temperature for the older adult should not be lower than 75°F.
For safety with older adults, flooring needs to be a solid single color, non-glare surface, and non-slip surface. Carpeting a portion of the wall can provide a buffer for noise and offer a variation in room décor. Carpeting is an effective sound absorber, and for most people it represents warmth, comfort, and a homelike atmosphere. There even has been speculation that the use of carpeting in institutional settings can reduce the number of fractures associated with falls. However, carpeting does create problems, which include the following: Static electricity and cling – Many older persons have a shuffling gait and incomplete toe lift during ambulation; this can produce uncomfortable static electricity, and the clinging of slippers and shoe soles to the carpeting could cause falls. Difficult wheelchair mobility – The more plush the carpet is, the more difficult it becomes to roll wheels on its surface. Cleaning –Spills are more difficult to clean on a carpeted surface; even with washable surfaces, discoloration can result. Odors – Cigarette smoke and other odors can cling to carpeting, creating unpleasant odors that last. Urine, vomitus, and other substances demand special deodorizing efforts that may not prove effective. Pests – The undersurface of carpeting provides a wonderful environment in which cockroaches, moths, fleas, and other pests can reside. To derive some of the benefits of carpeting, carpeting may be applied to some of the wall surface rather than the floor. This can provide a noise buffer, textural variation, and a décor with fewer housekeeping and maintenance problems than floor carpeting. Scattered and area rugs provide an ideal source for falls and should not be used. Tiled floor covering should be laid on a wood foundation rather than directly on a cement surface for better insulation and cushion. Bold designs can cause dizziness and confusion in ambulation; a single solid color is preferable. A non-glare surface is essential for older adults. Floor treatments that create a non-slip surface are particularly useful in bathrooms, kitchens, and areas leading from outside doors.
Furnishings should be appealing, functional, and comfortable. A firm chair with arm rests provides support and assistance in rising from or lowering into the seat; low, sinking cushions are difficult for older people to use. Avoid sitting on low furniture. Chairs with arms make it easier to get up. Chairs should also be of an appropriate height to allow the individual’s feet to rest flat on the floor with no pressure behind the knees. Love seats are preferable to larger sofas because no one risks being seated in the center without arm rests for assistance. Upholstery for all furniture should be easy to clean, so leather and vinyl coverings are more useful than cloth. Upholstery should be fire resistant, with a firm surface without buttons or seams in areas that come in contact with the body. Recliners can promote relaxation and provide a means for leg elevation, but they should not require strenuous effort to change positions. Tables, bookcases, and other furniture should be sturdy and able to withstand weight from persons learning for support. Foot stools, candlestick tables, plant stands, and other small pieces of furniture would be best placed in low-traveled areas, if they are present at all. Furniture and clutter should not obstruct the path from the bedroom to the bathroom. Drawers should be checked for ease of use. Sanding and waxing the corners and slides can facilitate their movement. In hanging mirrors, the height and function of the user must be considered; obviously, persons confined to wheelchairs will need a lower level than their ambulatory counterparts. Individuals with cognitive impairments need a particularly simple environment. Furniture should look like furniture and not pieces of sculpture. The use of furniture should be clear. Placement of a commode chair next to a sitting chair can be confusing and result in the improper use of both.
One of the most significant concerns about safety in later life relates to the incidence of falls. Falls are a major health problem for the older person, with serious implications for medical as well as financial outcomes. Falls account for more than 70% of the total injury-related health cost among people 60 years of age and older. Decreasing the risk of falling is one of the simplest and most important ways of maintaining healthy bones. Incorporating fall-prevention strategies into a person’s everyday life gets more important as one gets older, as falls are the leading cause of injury and injury-related death among older adults, and the odds of falling in any year after the age of 65 is about one in three. Slips and falls are a major cause of disability and a major cost.
Falls are a serious problem with need for ongoing prevention as part of the overall care of older person. Slips and falls are the main cause of injury for older people in the home. They are a major cause of disability and a major cost. Approximately one-third of older adults living at home and up to two-thirds of older adults in long-term care facilities fall each year. Studies have indicated that one third of persons age 75 years and older experience a fall each year and half of these experience multiple falls. Most falls occur in the home during normal routines. In the United States, falls are the leading cause of accidental death, and the ninth leading cause of death, in persons over 65 years of age. The rate of death due to falls rises with increasing age. The statistics related to falls point out the seriousness of this problem and the need for ongoing prevention as part of the overall care of the older person. Preventing falls and trauma is an important issue for nurses caring for older adults.
Falls – serious implications for older people About one third of the elder population over the age of 65 falls each year. At least 10% to 20% of these falls result in significant injury to the patient resulting in further use of costly health care services. The risk of falls increases proportionately with age. At 80 years, over half of seniors fall annually. Two-thirds of those who fall will fall again within six months. Falls are the most common cause of fatal injuries among elderly adults age 65 years and older, as well as the most common cause of nonfatal injuries in this population. Falls are the leading cause of death from injury among people 65 or over. Approximately 16,000 deaths in older Americans are associated with falls each year. In 2005, 15,800 people 65 and older died from injuries related to unintentional falls. The elderly account for seventy-five percent of deaths from falls. Injurious falls among elderly adults accounted for 1 in 10 emergency department visits among those 65 and older; 2.1 million emergency room visits in 2006. 30% of these patients (more than 433,000) had to be admitted to the hospital. The consequences of falls are serious: 20% of the hospital and 40% of the nursing home admissions of older adults are related to falls. Comparative studies ranking medical expenditures for older adults have shown that injuries rank higher than most diseases in health care costs. The annual cost of all medical care directly related to falls is about $20 billion. This number is expected to rise to $34 billion dollars annually by 2020 as the population of older adults continues to grow.
Twenty percent to 30% of people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas. These injuries can make it hard to get around and limit independent living. They also can increase the risk of early death (Alexander et al. 1992; Sterling et al. 2001). Falls are the most common cause of traumatic brain injuries, or TBI (Jager et al. 2000). In 2000, TBI accounted for 46% of fatal falls among older adults (Stevens et al. 2006). Most fractures among older adults are caused by falls (Bell et al. 2000). The most common fractures are of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand (Scott 1990). Even if no physical injury occurs, fall victims may develop a fear of falling again (I.e., post-fall syndrome) and reduce their activities as a result This can lead to unnecessary dependency, loss of function, decreased socialization, and a poor quality of life. Approximately 25 percent of community-dwelling people 75 or over unnecessarily restrict their activities because of fear of falling.
The risk of being seriously injured in a fall increases with age. In 2001, the rates of fall injuries for adults 85 and older were four to five times that of adults 65 to 74 (Stevens et al. 2005). Nearly 85% of deaths from falls in 2004 were among people 75 and older (CDC 2005). People 75 and older who fall are four to five times more likely to be admitted to a long-term care facility for a year or longer (Donald et al. 1999). Hip fracture very common and the incidence increases with age. Person over 85 is 10 times more likely to have a hip fracture than person age 65 Out of all types of fractures, hip fractures cause the greatest number of deaths. The National Center for Health Statistics annual mortality report shows that fall-related deaths among older adults increased sharply between 1998 and 2006. Older men tend to die from falls; older women experience more hospitalizations for fall-related hip fracture. The most profound effect of falling is the loss of independent functioning. Twenty-five percent of those who fracture a hip require nursing care in an institution for at least one year. Many never return home. 20% of older people die within 1 year. Only 33% regain their prefracture mobility and independence level.
Many factors contribute to the high incidence of falls in older adults (Box 17-2). The highest risk factor for an older adult having a fall is a history of a previous fall. Common risk factors include the following: Age-related changes: reduced visual capacity; problems differentiating shades of the same color, particularly blues, greens, and violets; cataracts; poor vision at night and in dimly-lit areas; less foot and toe lift during stepping; altered center of gravity leading to balance being lost more easily; slower responses; urinary frequency. Mental status: confusion, disorientation Impaired mobility, poor coordination, deconditioning, weakness Medications: particularly those that can cause dizziness, drowsiness, orthostatic hypotension, and incontinence, such as antihypertensives, sedatives, antipsychotics, diuretics Special toileting needs: urgency or urinating, diarrhea Unsafe clothing: poor-fitting shoes and socks, long robes or pants legs. Environmental hazards: wet surfaces, waxed floors, objects on floor, clutter, poor lighting Improper use of mobility aids: using canes, walkers, wheelchairs without being prescribed, properly fitted, or instructed in safe use; not using brakes during transfers.
Fall prevention is critical to preventing the negative consequences of falling among older adults. A program to prevent falls is essential to settings that provide services to older adults. Prevention begins with assessment. An evaluation of risk of falling should be incorporated into the assessment of each older client. The Fall Assessment Tool includes client and environmental factors that contribute to falls. Additional environmental risks may be present, depending on the physical setting. To administer the tool, simply circle the score that corresponds with the risk factor listed on the left-hand side of the instrument. The tool should be administered on admission to the facility or agency and again at specified intervals and when warranted by changes in health status. Scores of 15 and higher indicate high risk, and preventive fall measures should be implemented. The Hendrich II Fall Risk Model is another short tool that aids in assessing fall risk. The goals are to recognize older persons at risk for falling; to identify and correct fall risk factors.
A program to prevent falls is essential to settings that provide services to older adults. Prevention of falls in the clinical setting is one of the key goals of gerontological nursing practice. The goals are to recognize older persons at risk for falling; to identify and correct fall risk factors. Prevention strategies include: Review past falls and factors involved with past falls. Interdisciplinary approach to improve balance, gait, mobility, and functional independence. Reduce or eliminate environmental factors that contribute to fall risk: Put fall risk sign on door and chart. Removal of fall hazards such as area rugs and clutter. Appropriate nonglaring lighting (several diffuse lighting sources, and night light) Wall-to-wall carpeting or padding on the floor next to the bed. Carpet needs to be short pile, not shag. Bed and chair alarms to alert caregivers of older adult mobility. Accessibility of call bell Does patient have all their assistive devices from home: Cane, walker, eyeglasses, hearing aid? Does patient have safe and appropriate foot wear? Orientation to surroundings Medication - OTC and prescription medications should be reviewed for fall risk. Certain high-risk medications such as anticholinergic agents should be avoided in the elderly. Evaluate outcomes with revision of the plan as needed.
Fall Risk Video – Start 1:40, end 9:33 Older adults can take several steps to protect their independence and reduce their risk of falling. They can: Exercise regularly : Exercise improves your strength, balance, coordination and flexibility – all important factors in preventing falls. Try gentle yet effective exercises such as walking, water workouts or tai chi. Functional footwear - Get rid of your high heels, slippery-soled shoes and floppy slippers and sandals. Wear rubber-soled, low-heeled shoes that fully support your feet. Wearing only socks or shoes/slippers with smooth soles on stairs or floors without carpet can be unsafe. Make sure that your shoes fit properly. Avoid shoes with thick soles. These can easily get hung up on a curb or step. Tie your laces tightly or use fabric fasteners. Remove hazards Most homes are filled with falling hazards. Here are some tips to help you make your home a safe haven. Ask their doctor or pharmacist to review their medicines–both prescription and over-the counter–to reduce side effects and interactions. Improve the lighting in their home. Reduce hazards in their home that can lead to falls. Let there be light The ability to sense color and motion gets more difficult as you get older, but using high-watt bulbs (100w) can make it easier. Here are some other illuminating tips: Put a light near your bed so you can easily switch it on before getting up in the dark. Consider installing glow-in-the-dark or illuminated switches that are easy to find. Place night-lights in your bedroom, bathroom and walkways. Never try to negotiate stairs in the dark. Keep flashlights handy. Treating poor vision is a crucial step to avoiding steps
The incidence of falls occurs most frequency at home. At least one-third of all falls in the elderly involve environmental hazards in the home Most common hazard for falls is tripping over objects on the floor Other factors include poor lighting, loose rugs, lack of grab bars or poorly located/mounted grab bars, and unsturdy furniture Tack down all carpets and area rugs firmly to the floor. Keep electric cords and telephone wires near walls and away from walking paths.
Encourage patient/ family to conduct a walk-through of the home to identify possible problems that may lead to falling Nurse home visit might also be useful to identify risk factors and recommend appropriate actions
For all stairways, check lighting, handrails, and the condition of the steps and coverings. Stairs should be lighted so that each step, particularly the step edges, can be clearly seen while going up and down stairs. The lighting should not produce glare or shadows along the stairway. Paint edges of outdoor steps white to see them better at night. Repair cracks/ abrupt edges of sidewalks and driveways Install handrails on stairs & steps. Remove high doorway thresholds Trim shrubbery along pathway to home Keep walk areas clear of clutter, rocks & tools Keep walk areas clear of snow & ice Install adequate lighting by doorways & along walkways leading to doors
Use change in color to denote changes in surface types or levels Secure rugs with nonskid tape as well as carpet edges. Tack down all carpets and area rugs firmly to the floor. Avoid throw rugs Remove oversized furniture & objects. Make sure your sofas and chairs are the right height for you, so that you can get in and out of them easily. Have at least one phone extension in each level of the home & post emergency numbers at each phone. Keep emergency numbers in large print near each telephone.
Add electrical outlets Reduce clutter. Keep areas where you walk tidy. Don’t leave things on the floor—you might trip on them. Check lighting for adequate illumination & glare control Maintain nightlights or motion-sensitive lighting throughout home. Use contrast in paint, furniture & carpet colors At least one smoke detector should be placed on every floor of home, with batteries that are replaced often. Make sure detectors are placed near bedrooms, either on the ceiling or to 12 inches below the ceiling on the wall. Locate smoke detectors away from air vents. Install electronic emergency response system if needed. Usually, you wear a button on a chain around your neck. If you fall or need emergency help, you just push the button to alert the service. You can find local “medical alarm” services in your yellow pages. Most medical-insurance companies and Medicare do not cover items like home monitoring systems. Be sure to ask about cost. You will probably have to pay for it yourself.
Keep commonly used items within easy reach Instruct pt to use sturdy step stool when reaching for something from a high shelf Make sure appliance cords are out of the way. Lamp, extension and telephone cords placed outside the flow of traffic. Cords stretched across walkways may cause someone to trip. Remove cords from under furniture or carpeting. Replace damage and frayed cords. Avoid using floor polish or wax in order to reduce slick surfaces. Stay away from a freshly washed floor.
Keep electrical & telephone cords out of the way Arrange furniture so that pt can easily move around it (especially low coffee tables) Make sure chairs & couches are easy to get in & out of Remove caster wheels from furniture Use television remote control & cordless phone
Put in a bedside light with a switch that is easy to turn on and off (or a touch lamp) Have a nightlight Locate telephone within reach of bed Adjust height of bed to make it easy to get in & out of Have firm chair, with arms, to sit & dress
Keep free of clutter Make sure carpet is secured & get rid of throw rugs (no scatter rugs!) Install tightly fastened hand rails running the entire length and along both sides of stairs. Handrails should be 34 inches high & have a diameter of about 1.5 inches
Add bright tape strips (red, orange) to the edge of each stair to make them more visible. If you plan to carpet your stairs, avoid deep-pile carpeting, and patterned and dark-colored carpeting that can make it difficult to see the edges of the steps clearly. Optimal stair dimensions are 7.2 inch riser heights with either an 11 or 12 inch tread width Do the steps allow secure footing? Worn treads and worn and loose carpeting can lead to insecure footing, resulting in slips and falls. Are the steps even and of the same size and height? Even a small difference in step surfaces or riser heights can lead to falls. Have adequate lighting in stairways, hallways & pathways, with light switches placed at each end. Even if you are very familiar with the stairs, lighting is an important factor in preventing falls. You should be able to turn on the lights before you use the stairway from either end. Are light switches located at both the top and bottom of the stairs?
Medical supply stores and health care equipment suppliers offer a variety of devices that can make the bathroom and other living areas safer and more functional. Sometimes less expensive replicas can be homemade and be equally effective. It is much wiser to invest in and use these assistive devices to prevent an injury than to wait until an injury occurs. Many accidental injuries occur in the bathroom and can be avoided with common sense and inexpensive measures. Particular attention should be paid to the following aspects. Lighting – A small light should be on in the bathroom at all times. Because urinary frequency and nocturia are common, older adults use the bathroom often and can benefit from the increased visibility. A nightlight in the bathroom can make night trips to the bathroom safer. Constant lighting is especially helpful if the switch is located outside the bathroom, so that the individual does not have to enter a dark area and then search for a switch. Faucets – Lever-shaped faucet handles are easier to use than round ones or those that must have pressure exerted on them. Older people can risk falling or burning themselves by releasing too much hot water as they struggle to turn a faucet handle. This problem supports the need to control hot water temperature centrally. Color coding the faucet handles makes differentiation of hot and cold easier than small letters alone. Tubs and shower stalls – Nonslip surfaces are essential for tubs and shower floors. Add nonskid mats, appliques, or textured strips to bathtubs. Install grab bars on walls around the tub and beside the toilet, strong enough to hold pt’s weight. Grab bars on the wall and safety rails attached to the side of the tub offer support during transfers and a source of stabilization when bathing. Floor surface – Towels, hair dryers, and other items should not be left on the bathroom floor, and throw rugs should not be used. For older people, falls are dangerous under any circumstance, but the high likelihood of falling and striking one’s head on the hard surface of a tub or toilet increases the potential seriousness of the fall. Leaks should be corrected to avoid creating slippery floors, which are another cause of falls. Mount liquid soap dispenser on the bathtub-wall. A shower or bath seat offers a place to sit when showering and, for tub bathers, a resting point when lifting to transfer out of the tub. Because a drop in blood pressure may follow bathing, it may be beneficial to have a seat alongside the tub to enable the bather to rest when drying.
Mount grab bars near toilets and on both the inside and outside of your tub and shower.
Install a portable, hand-held shower head. Add padded bath or shower seat. A shower or bath seat offers a place to sit when showering and, for tub bathers, a resting point when lifting to transfer out of the tub. Because a drop in blood pressure may follow bathing, it may be beneficial to have a seat alongside the tub to enable the bather to rest when drying. Toilets – Grab bars or support frames aid in the difficult task of sitting down and rising from a toilet seat. Install raised toilet seat. Because the low height of toilet seats makes them difficult for many older people to use, a raised seat attachment could prove useful. Place non-skid mats, strips, or carpet on all surfaces that may get wet. This nonskid bath mat can help prevent slippage in the shower or tub. Electrical appliances – The use of electric heaters, hair dryers, and radios in the bathroom produces a considerable safety risk. Even healthy, agile persons can accidentally slip and pull an electrical appliance into the tub with them.
Driving is one of the instrumental activities of daily living for most elders because it is essential to obtaining necessary resources for those individuals who live in rural and suburban areas. Older adults drive an estimated 84 billion miles annually. Lack of accessible transportation may contribute to other problems Social withdrawal Poor nutrition Neglect of health care Although when examined as a group, drivers over age 60 have lower accident rates than persons under age 30, accident rates begin to skyrocket after age 75. When compared with younger age-groups, people older than 70 years are more likely to be involved in a crash and more likely to die in that crash. After age 85, older drivers are involved in four times the number of accidents on a mile-per-mile bases as persons aged 50 to 59, and when they are involved in accidents, they are 15 times more likely to die than drivers in their 40s. In an emotional case that sparked national debate about the rights of elderly drivers, 89-year-old George Russell Weller was convicted Friday of negligently causing the deaths of 10 pedestrians when he careened through the crowded Santa Monica Farmers' Market in July 2003. Weller was 86 on July 16, 2003, when his 1992 Buick Le Sabre plowed through the farmers market, killing 10 people -- ages 7 months to 78 years -- and injuring more than 60 others. His car reached an estimated speed of 60 mph, and he later told authorities he had mistaken the accelerator for the brake pedal.
Giving up mobility and independence afforded by driving one’s own car has many psychological ramifications, as well as inconveniences. Age-related changes in driving skills, including vision changes, cognitive impairment, and various medical illnesses and functional impairments, are all factors related to driving safely for older adults. Mental – Reaction time is one of the most crucial functions to safe driving. This slows with age, but increasing distance between other cars and objects may help some older drivers. Vision – Good vision is essential to safe driving. An older person may notice difficulties focusing on objects and switching focus from near to far. The ability to see fine detail may diminish. Peripheral vision may also change with age. This is significant, since about 98% of what we see when we drive is seen first peripherally. Driving at night may become more difficult due to clarity in sight issues. As we get older, we need more light to see clearly. Approaching headlight glare may make it harder to adjust to. Hearing – Some hearing loss is common in people 65 and older. High-pitched sounds may become less audible. This is important because horns, sirens, and train whistles are high-pitched. Nurses should assist older drivers in identifying risks to safe driving (e.g., poor vision, use of medications that reduce alertness, slower reflexes) and encourage them to evaluate their continued ability to drive safely.
Assessments of functional capacities often neglect driving. Health care professionals should evaluate whether an individual can drive, feels safe driving, and has a driver’s license. Slower response and reaction times may be safety hazards. Slower movement and poor coordination subject older adults to falls and other accidents. Older pedestrians may misjudge their ability to cross streets as traffic lights change, and older drivers may not be able to react quickly enough to avoid accidents. If family members are not available to escort and transport these individuals, assistance may be obtained through local social service agencies. Local chapters of the Automobile Association of America and senior citizen groups can be contacted for safe driving classes that could be offered to older adults. If such programs do not exist in the community, the gerontological nurse could stimulate interest and assist in developing programs as a means of advocating for the safety of older drivers.
Factor often contributing to feelings of isolation for older adults is decision, sometimes imposed by others, to give up one’s driver’s license and no longer drive. Persons who lose the privilege of driving often feel lonely or anxious because they have fewer opportunities to be with friends or involved in activities. “ Individuals may not be licensed if they suffer from a mental or physical problem that might keep them from driving safely” (NCDOT)
Rather than cease driving altogether, some older adults may find it useful to restrict their driving to daylight hours, noncongested areas, or good weather. The toughest spots for senior drivers are intersections. That's where most accidents involving elderly drivers occur, and where the most serious car crashes take place. Forty percent of the fatal collisions for people 70 and older occur at intersections and involve other vehicles, compared with just 23 percent of such crashes for 35-to-54-year-olds. So intersections — and how and whether they can be modified in the interests of elderly drivers — are attracting increasing attention from researchers, advocacy groups and government agencies. The most extensive and recent research on traffic intersections has shown that senior drivers flirt with many sources of danger near, at or within intersections. One of them is a higher tendency to run into cars in front of them. But by far, the inability to safely execute an unprotected left-hand turn — one without a left-turn signal — is their stiffest challenge.
Avoid distractions. If necessary to use cell phone, first pull over at convenient place Follow 4-second rule when following another vehicle Obey traffic & motor vehicle laws, signs, signals Adjust speed to road & weather conditions Expect the unexpected & always drive defensively
True. Nurses should assist older drivers in identifying risks to safe driving and encourage them to evaluate their continued ability to drive safely. Modifications can be made that allow older adults to continue to be safe drivers.
Change is usually stressful, regardless of whether change is perceived as positive or negative Changing life situations for older adults can affect safety and security by posing unfamiliar routes, routines, and persons in the environment Routine and familiarity Familiarity is very important to someone with Alzheimer's disease. Too much change can be confusing and disorienting. The stress of having to cope with sudden or significant change can make symptoms worse.
Vulnerability to Natural Disasters Older people are at great risk during/ after disasters Nurses must participate in disaster planning to support older people during these times Older people may be less likely to seek help than younger people during disasters and may not get as much assistance as younger individuals
Safety & Falls NURS 4100 Care of the Older Adult Spring 2013 Joy A. Shepard, PhD(c), MSN, RN, CNE, BC 1
Objectives Describe the effects of aging on safety Discuss the significance of the environment to physical and psychological health and well- being List the impact of age-related changes on the function and safety of the environment Describe adjustments that can be made to the environment to promote safety and function of older persons 2
Objectives Identify hazards in the home and ways to minimize them Discuss factors that contribute to falls, consequences of falls, and ways to prevent falls in the older adult List ways to promote safe driving in older adults Explore the unique challenges of natural disasters to the older adult population Discuss assistive technology 3
Introduction Older persons: same hazards as other adults Risks compounded by: Age-related factors Increased vulnerability Nursing assessment: review of safety risks Interventions: address threats to safety 4
Aging Risks to Safety Accidents among top 10 causes of death in older adults Older women: higher rate of injuries than any other adult female age group Death rate highest for 85+ age group (Table 17-2, p. 192) Falls are most common cause of injury/ death in seniors 5
High Risk of Infections in Older Adult Population Age-related changes Altered antigen-antibody response High prevalence of chronic disease Atypical symptomatology: delayed dx of infection and higher rate of mortality Greater incidence nosocomial infections Pneumonia & influenza: 7th leading cause of death in older adults (noted changes from Table 1-4) Hand hygiene, sanitation, vaccinations Influenza – annually Pneumonia – every 5 yrs 6
Question Because illness in older adults is complicated by the normal changes of aging and multiple chronic conditions, many older adults do not display the usual signs and symptoms of illness. Atypical presentation of illness in older adults includes all of the following EXCEPT: (A) Anorexia (B) Cough (C) Confusion (D) Falls (E) Incontinence 7
Safety Risks Involving Medication Use in the Elderly Altered pharmacokinetics Self-administration problems High volume of drugs used with older adults (polypharmacy) Risk for adverse effects and accidents Higher rate of hospital admission related to inappropriate drug administration 8
Question Medications act differently in older adults than in younger adults for all of the following reasons EXCEPT: (A) Older persons tend to have increased total body fat and decreased lean mass (B) Older persons tend to have increased body water and decreased total body fat (C) The kidneys become less efficient with age (D) The liver decreases in size and function with age (E) The gastrointestinal system slows with age 9
Question Is the following statement true or false? Altered pharmacokinetics, self- administration of drugs, and the high volume of drugs consumed by older adults can lead to increased risks to safety. 10
Importance of Environment to Health and Wellness Microenvironment: Immediate surroundings Macroenvironment: Elements in larger world Environment – continued development, stimulation, and satisfaction to enhance well- being Environmental needs and Maslow’s theory (lower-level needs must be met first) 11
Impact of Aging on Environmental Safety and Function Limitations posed by chronic disease: special environmental problems for older adults (Table 17-5, p. 195) Older adults: safe, functional, comfortable, personal, and normalizing environment to compensate for limitations 14
Factors Affected by Lighting Function Orientation Mood Behavior 15
Using Lighting to Promote Safety Several diffuse lighting sources No fluorescent lighting Control bright lights and direct sunlight (glare) Nightlights: promote visibility & orientation Keep charged flashlight at bedside Natural light: maintain body rhythms 16
Temperature and the Older Adult Body temperature: tactile sensitivity, vigilance performance, and psychomotor tasks Older adults: lower than normal body temperatures Maintain adequate environmental temperature Recommended room temperature: 75°F 17
Question Is the following statement true or false? Room temperatures less than 70°F can lead to hypothermia in an older adult. 18
Risks Associated With Carpeting Static electricity and cling Difficult wheelchair mobility Cleaning Odors Pests Falls 19
Falls & the Older Person Falls: major health problem for older adults in all settings Leading cause of injury deaths for people 65 and older Most frequent reason for trauma admissions among the elderly Major cause of disability and a major cost 22 22
Falls: Serious Problem Serious problem need for ongoing prevention Main cause of injury in the home Most falls occur in home during normal routines Serious implications for older person Leading cause of accidental death in US (for older adults) Deaths from falls increase with age 23 23
How Big is the Problem? Annually: 1/3 adults age 65 and older sustain serious falls Leading cause of injury deaths Most common cause of nonfatal injuries Hospital admissions for trauma Deaths, emergency room visits, hospitalizations 20% of hospital and 40% of nursing home admissions related to falls $20 billion annually Projected > $34 billion (2020) Rates of fall-related deaths among older adults rose significantly over the past decade. http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html 24
Falls: Outcomes 20-30%: bruises, hip fx, or head traumas Injuries can make it hard to get around Limit independent living Increase the risk of early death Most common cause of traumatic brain injuries (TBI) TBI accounts for 50% of fatal falls among older adults. Majority of fx in elderly caused by falls Fear of falling – limit activity http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html 25
Fractures: Age-Related, Serious Consequence of Falls Most common fall-related injuries Osteoporotic fx of hip, spine, and forearm (wrist) Risk sustaining a hip fx increases with age A person ≥ 85 yrs 10 times more likely to sustain hip fx Hip fx: greatest number of deaths After hip fx 20% of older people die within 1 yr 25% remain in institution for at least 1 yr Many never return home Only 33% regain prefracture functional level 26 26
Risk Factors for Falls (Box 17-2, p. 201) Most falls occur near beds, bathrooms, & hallways. Some of the most common reasons for falls in the hospital are: Fall history (at least one previous fall) Age Mental status: confusion, disorientation Sensory deficits (poor eyesight, hearing) Impaired ability to walk and move, weakness, poor coordination Effects of medications: such as sedatives, tranquilizers, and pain medication (benzodiazepines, psychotropics, opioids, anticholinergics) Special toileting needs: urgency of urinating, diarrhea Unsafe clothing (improper footwear, long robes or pants legs); clutter 27
Fall Risk Assessment Prevention begins with assessment Commonly used fall risk instruments in acute/ long-term care Fall Assessment Tool Hendrick II 28
Fall Risk Reduction Interventions Prevention of falls in the clinical setting is one of the key goals of gerontological nursing practice*** Recognize older persons who are at risk for falling Identify and correct fall risk factors Improve balance, gait, and mobility Improve functional independence Environmental modifications Medication review Evaluate outcomes Revise plan as needed 30 30
How Can Older Adults Prevent Falls? Exercise regularly Functional footwear (rubber-soled, low-heeled shoes; no floppy slippers or slick socks) Avoid clothing that drags on the ground Remove hazards that can lead to falls Improve lighting in the home Review medications–both prescription & OTC– to reduce side effects and interactions Check vision at least once a year 31
Falls: Environmental Hazards Falls occur most frequently at home One-third of falls: hazards in the home Most common hazard for falls: tripping over objects on floor Other factors: poor lighting, loose rugs, no grab bars, poorly located/mounted grab bars, & unsturdy furniture 33 33
Injury Prevention Tips Conduct walk-through of home Identify possible fall hazards Nurse home visit Identify risk factors Recommend appropriate actions Home Safety Tips & Tools Home Inspection P.1 Home Inspection P.2 34 34
Outdoors Cracks/ uneven Walk areas clear of edges snow & ice Handrails Adequate lighting High doorway thresholds Shrubbery Walk areas clear of clutter 35 35
All Living Spaces Color change: changes in surface types, levels Nonskid tape: rugs, carpet edges No throw rugs No oversized furniture & objects Phone extension at each level of home Emergency numbers 36 36
All Living Spaces Electrical outlets Reduce clutter Lighting: adequate illumination, control glare Nightlights/ motion-sensitive lighting throughout home. Contrast Working smoke alarms – every floor Electronic emergency response system (e.g., Lifeline Medical Alert) Installing Smoke Alarms in Your Home 37
Kitchen Commonly used items within easy reach Sturdy step stool Appliance cords out of way No floor polish or wax; wet floors 38 38
Living, Dining & Family Rooms Electrical & telephone cords out of way Furniture: easy to move around (especially low coffee tables) Chairs & couches: easy to get in/ out No caster wheels on furniture Television remote control & cordless phone 39 39
Bedroom Bedside light Bed height: easy to Switch easy to get in/out turn on/off Firm chair with Touch lamp arms Nightlight Telephone within reach of bed 40 40
Stairways, Hallways & Pathways Clutter-free Carpet: secured NO throw/ scatter rugs! Tightly fastened hand rails for stairs Entire length Both sides Handrails: 34” high; diameter 1.5” 41 41
Stairways, Hallways & Pathways Brightly colored Adequate lighting tape (red, Light switches: orange) to steps each end Stair dimensions: 7.2” riser heights, 11-12” tread width 42 42
Bathrooms Small light on at all Floor surface free of clutter times Nonslip surfaces Lever-shaped faucet Nonskid mats handles Appliqués bathtubs Shower or bath seat Grab bars/ safety rails: strong enough to hold weight Walls around tub Liquid soap dispenser 43 43
Transportation & Safe Driving Driving: important IADL Essential to obtaining necessary resources Lack of accessible transportation: Social withdrawal Poor nutrition Neglect of health care MVC and elderly Tragic case of George Russell Weller 55
Transportation & Safe Driving Giving up driving: many negative ramifications Factors related to safe driving for older adults: Age-related changes in driving skills Vision changes Cognitive impairment Medical illnesses/ functional impairments 56
Transportation & Safe Driving Assessment of functional capacity: Slower response/ reaction times Slower movement Poor coordination Poor judgment Denial or lack of awareness 57
Loss of Driving Privileges Decision to give up driver’s license Feelings of isolation Lonely, anxious “Individuals may not be licensed if they suffer from a mental or physical problem that might keep them from driving safely” (NCDOT) http://www.ncdot.org/dmv/driver_services/drivingpublic/applying.ht ml#Step%204 58
Action Strategies for Driving Cessation (Negative) Imposed Report person to division of motor vehicles for possible license suspension Use of deception or threats such as false keys, disabling the car, saying car was stolen Attempts to order or control, such as provider writing a prescription Commands from children to stop driving 59
Action Strategies for Driving Cessation (Positive) Involved Family members and individual come to mutual agreement Dialogue ongoing from earliest signs of cognitive impairment Arrangements made for alternative transportation when needed & acceptable to individual Any abrupt change in an older person’s behavior (such as nearly running into a lamp post with a car) should be evaluated by his or her health care professional Giving up keys 60
Safe Driving Tips (Elderly) Drive on familiar roads & streets Wear seat belt Avoid heavy, fast-moving traffic Drive short distances Keep eyes on road Avoid driving at night Avoid left-hand turns Avoid driving in poor weather (heavy rain, ice, snow) 61
Question Is the following statement true or false? Rather than cease driving altogether, some older adults may find it useful to restrict their driving to daylight hours, noncongested areas, and good weather 67
Effects of Changing Life Situations Change is usually stressful, regardless of whether change is perceived as positive or negative Changing life situations for older adults can affect safety and security by posing unfamiliar routes, routines, and persons in the environment Clients with dementia Routine and familiarity very important Too much change – confusing and disorienting Stress of coping with sudden or significant change can make symptoms worse 69
Influences of Changing Health and Disability on Safety and Security Vulnerability to Natural Disasters Older people: great risk during/ after disasters Disaster planning to support older people Older people: Less likely to seek help Not as much assistance 70
Advantages/ Role of Assistive Technology Maintain independence Decreased need for personal care Promote function and adaptation Increase QOL Ability to live safely at homeSmart House Monitors Senior Safety 73
Common Applications Assistive Technology Position and Mobility Walkers, canes, motorized chairs, mobility devices, straps Environmental Access Modifications to buildings, increased accessibility, Braille Environmental controls Switches that control the surroundings such as touching a switch for lights, TV, phone, opening doors via mouthstick or key pad 74